PROJECTSUMMARY?PROJECT5 Anadageinacutecaremedicineisthatwhilepatientsdon?twanttodiebadly,theyalsodon?twanttodie. Increasingly,hospital-basedphysiciansmustnegotiatethisdifficultbalance.Theymustimplementtime- sensitivetreatmentalgorithmsforacutecareconditionssuchasseveresepsis,stroke,andheartattackto mitigatemortalityriskwhilesimultaneouslyconsideringpatients?goalsofcaretorespecttheirend-of-life(EOL) treatmentwishes.Makingthisprocessevenmorechallengingisthatoftenthephysicianwillbeseeingthe patientforthefirsttime.Tothisend,hospitalistsoftenhaveadvancecareplanning(ACP)discussionswith patientsandtheirfamilies,oftenregardingadvancedirectives(ADs).Yetratesoftreatment-limitingADs implementedinthehospital(e.g.,?do-not-resuscitate?(DNR)orders)varywidelyfromhospitaltohospitalfor otherwisesimilarseriouslyillolderadults.Similarly,ratesofcardiopulmonaryresuscitation(CPR)and mechanicalventilationamongICUpatientswithpre-existingDNRordersvaryfromICUtoICU,mostlikely reflectingbothover-useandunder-useoftreatments.Thegoalofthisprojectistoimprovethequalityof decisionmakingforseriously-ill,hospitalizedolderadults.Basedonourpriorresearchinvolvingparticipant observation,simulation,andcognitiveinterviewing,ouroverarchinghypothesisisthatasinglephysician judgmentcontributestothesevariations,whetherornotapatientisnearthe?endoflife?(EOL).We hypothesizethatthisjudgmentisnotsimplyaproductofexplicit,knowledge-basedprognostication,butis influencedbyphysicians?heuristics(implicit,unconsciouscognitionrelatedtopatternrecognition)andbylocal socialnorms.Thespecificaimsofthisprojectare:1)Tounderstandthecognitiveprocessesthatinfluence hospital-basedphysicians?judgmentthatapatientisnearthe?EOL,?andthereforetheirlikelihoodofACP discussions;?2)ToexploretheassociationbetweenacutecareACPandpatientcareoutcomes;?and3)Totest theeffectofinterventionsdesignedtoinfluencephysiciancognitiveprocesses,comparedtousualcareQI alone,onthelikelihoodofACPdiscussionsusingarandomizedtrial.Toachievetheseaims,wewillusea combinationofobservationalandexperimentalresearchlinkingproprietaryclinicaldatawithclaimsin partnershipwithanationalphysicianmanagementgroup.Thisgrouprepresents2,500hospital-based physiciansat250communityhospitalsacrosstheU.Swhomanageapproximatelyhalfamillionadmissions amongpatients65andoldereachyear.Thisprojectusesresourcesfromall3Cores,providesadata collectionplatformforCoreC?svalidationofnetworkmeasuresemployedbyallprojects,andofferssynergies withProject1and2,includinghowlabelingapatientwithdementiamayinfluencephysicians?decisionsabout acutecaretreatment,ACPdiscussions,andADinterpretation(Project1)andtheassociationbetweenhospital measuresofriskyprescribingandpatientoutcomes(Project2).